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Socioeconomic Disparities in the Surgical Management of Craniosynostosis
Alexandra Junn, Sacha Hauc, Mohammad Ali Mozaffari, Jacob Dinis, Michael Alperovich
Plastic Surgery, Yale School of Medicine, New Haven, Connecticut, United States

Objectives: Prior research has demonstrated discrepancies in the use of cranial vault remodeling (CVR) and strip craniectomy (SC) in various populations. This is the first study to use the ICD-10 codes to investigate disparities in surgical management for craniosynostosis.
Design: We compared the socioeconomic and geographic characteristics of patients who underwent CVR procedures against those who received SC. We further compared endoscopic with open SC and CVR with open SC to determine whether differences between CVR and SC remained regardless of the SC approach. Data analysis relied on the Kids" Inpatient Database (KID), a large publicly available all-payer inpatient care database of the United States, and identified a weighted estimate of 4,988 patients who were both diagnosed with craniosynostosis and had undergone a corrective procedure. Patient and hospital characteristics were analyzed using a student"s t-test for continuous variables and a chi-square test for categorical variables. Univariable analysis was utilized to compare the relative odds of undergoing a certain procedure type based on a variety of demographic and hospital-level variables.
Results: A greater proportion of patients who had private insurance (58.14% vs. 47.49%) or were self-pay (8.06% vs. 6.28%) underwent SC, while a higher percentage who were covered under Medicaid (46.23% vs. 32.8%; P<0.001) received CVR. This represented a 1.76 times higher likelihood of receiving SC if the patient carried private insurance, and a 1.81 times higher likelihood if the patient was self-pay (P=0.01). A greater proportion of patients coming from the highest income quartile also underwent SC (33.06% vs. 22.03%; P<0.001). Infants from the highest income quartile were almost 2 times as likely to receive SC rather than CVR (P<0.001). In patients undergoing SC, we identified a total of 295 undergoing endoscopic SC and 228 undergoing open SC. In terms of insurance, private insurance represented a greater proportion of patients undergoing endoscopic SC (66.19% vs. 50%; P=0.0033). Patients who came from the highest income quartile were more likely to undergo endoscopic SC. Finally, there were no differences between CVR and open SC in terms of insurance type, family income, or any hospital characteristics. No differences in terms of race were observed between any of the groups (P=0.883).
Conclusions: Our study found that the difference between CVR and SC can be attributed to the difference in the endoscopic vs. open approaches to SC. Compared to CVR, patients receiving endoscopic SC came from wealthier and commercially insured families. The same differences were not observed when comparing CVR with open SC. In contrast to previous studies, our analysis did not identify significant differences in procedure type based on race.


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